<!DOCTYPE html>
<html lang="en" data-ng-app="patientMgmtModule">
    <head>
        <meta charset="ISO-8859-1">
        <meta name="viewport" content="width=device-width, initial-scale=1.0">

        <base href="/HMS_Web/">

        <script src="https://ajax.googleapis.com/ajax/libs/angularjs/1.0.7/angular.min.js"></script>
        <script src="http://code.jquery.com/jquery.js"></script>
        <script src="js/bootstrap.min.js"></script>
        <script src="js/PatientCtrl.js"></script>
        
        <link href="css/bootstrap.min.css" rel="stylesheet" media="screen">
        <link href="css/bootstrap-responsive.min.css" rel="stylesheet">
        <link href="css/hms_styles.css" rel="stylesheet">

        <style>
            .form-horizontal .control-label{
            /* text-align:right; */
            text-align:left;
            }
        </style>

        <title>HMS - {{Patient.workflow}}</title>
    </head>
    <body ng-controller="NewPatientCtrl">
        <div class="container-fluid">
            <div class="row-fluid">
                <div class="span8 offset2 hms-section-header" hms-section-name="{{Patient.workflow}}">
                    <form class="form-horizontal" ng-submit="addPatient()">
                        <table class="table table-bordered table-striped table-condensed table-hover">
                            <thead>
                                <tr>
                                  <th>
                                    <label><strong>Enter Patient Information:</strong></label>
                                  </th>
                                </tr>
                            </thead>
                            <tbody>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientFName">First Name:</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientFName" data-ng-model="Patient.patientFName" placeholder="First name" required>
                                    </td>
                                </tr>
                                <tr>
                                        <td>
                                            <label class="control-label" for="patientLName">Last Name:</label>
                                        </td>
                                        <td>
                                            <input type="text" id="patientLName" data-ng-model="Patient.patientLName" placeholder="Last name" required>
                                        </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientAge">Age:</label>
                                    </td>
                                    <td>
                                        <input type="number" id="patientAge" data-ng-model="Patient.patientAge" placeholder="Age" required>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label>Sex:</label>
                                    </td>
                                    <td>
                                        <div class="btn-group" data-toggle="buttons-radio" data-ng-init="Patient.patientSex=1">
                                          <button type="button" class="btn btn-primary active" ng-click="Patient.patientSex=1">Male</button>
                                          <button type="button" class="btn btn-primary" ng-click="Patient.patientSex=2">Female</button>
                                        </div>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientParentSpouse">Parent / Spouse:</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientParentSpouse" data-ng-model="Patient.patientParentSpouse" placeholder="Parent / Spouse name" required>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientAddress1">Address 1:</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientAddress1" data-ng-model="Patient.patientAddress.patientAddress1" placeholder="Address 1" required>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientAddress2">Address 2:</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientAddress2" data-ng-model="Patient.patientAddress.patientAddress2" placeholder="Address 2">
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientCity">Location:</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientCity" data-ng-model="Patient.patientAddress.patientCity" placeholder="Village / City" required>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientContactNbr">Contact Number(s):</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientContactNbr" data-ng-model="Patient.patientContactInfo.patientContactNbr" placeholder="Phone Number" required>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientQual">Qualification:</label>
                                    </td>
                                    <td>
                                        <select id="patientQual" ng-model="Patient.patientQual" ng-init="Patient.patientQual='Select one'" class="nav-select" required>
                                            <option value='Select one'>Select one</option>
                                            <option value='Uneducated'>Uneducated</option>
                                            <option value='9th or Less'>9th or Less</option>
                                            <option value='10th'>10th</option>
                                            <option value='Intermediate / 10+2'>Intermediate / 10+2</option>
                                            <option value='Undergraduation'>Undergraduation</option>
                                            <option value='Post Graduation'>Post Graduation</option>
                                        </select>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientOccupation">Occupation:</label>
                                    </td>
                                    <td>
                                        <input type="text" id="patientOccupation" data-ng-model="Patient.patientOccupation" placeholder="Occupation" required>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                        <label class="control-label" for="patientComments">Comments:</label>
                                    </td>
                                    <td>
                                        <textarea id="patientComments" data-ng-model="Patient.patientComments" rows="3" placeholder="Comments"></textarea>
                                    </td>
                                </tr>
                                <tr>
                                    <td>
                                    </td>
                                    <td>
                                        <span class="pull-right">
                                          <button type="submit" class="btn btn-primary" data-loading-text="Saving...">Save changes</button>
                                          <button type="button" class="btn">Cancel</button>
                                        </span>
                                    </td>
                                </tr>
                            </tbody>
                        </table>
                    </form>
                </div>
            </div>
        </div>
    </body>
</html>